Health determinants among refugees in Austria and Germany: A propensity-matched comparative study for Syrian, Afghan, and Iraqi refugees

In recent years, Germany and Austria have been among the leading European receiving countries for asylum seekers and refugees (AS&R). The two countries have cultural and economic similarities, but differ, for example, in their health care systems, with AS&R having unrestricted access to health services upon arrival in Austria, but not in Germany. This study investigates the determinants of health among refugees in Austria and Germany, and how these determinants differ between the two countries. We analyze comparable and harmonized survey data from both countries for Syrian, Afghan, and Iraqi nationals aged 18 to 59 years who had immigrated between 2013 and 2016 (Germany: n = 2,854; Austria: n = 374). The study adopts a cross-sectional design, and uses propensity score matching to examine comparable AS&R in the two receiving countries. The results reveal that the AS&R in Germany (72%) were significantly less likely to report being in (very) good health than their peers in Austria (89%). Age and education had large impacts on health, whereas the effects of length of stay and length of asylum process were smaller. Compositional differences in terms of age, sex, nationality, education, and partnership situation explained the country differences only in part. After applying propensity score matching to adjust for structural differences and to assess non-confounded country effects, the probability of reporting (very) good health was still 12 percentage points lower in Germany than in Austria. We conclude that many of the determinants of health among AS&R correspond to those in the non-migrant population, and thus call for the implementation of similar health policies. The health disadvantage found among the AS&R in Germany suggests that removing their initially restricted access to health care may improve their health.

An overview of systematic reviews on mental health promotion, prevention, and treatment of common mental disorders for refugees, asylum seekers, and internally displaced persons

BACKGROUND

Migrants who have been forced to leave their home, such as refugees, asylum seekers, and internally displaced persons (IDP), are likely to experience stressors which may lead to mental health problems. The efficacy of interventions for mental health promotion, prevention, and treatment may differ in this population.

OBJECTIVES

With this overview of systematic reviews, we will map the characteristics and methodological quality of existing systematic reviews and registered systematic review protocols on the promotion of mental health and prevention and treatment of common mental disorders among refugees, asylum seekers, and IDPs. The findings from this overview will be used to prioritise and inform future Cochrane reviews on the mental health of involuntary migrants.

METHODS

We searched Ovid MEDLINE (1945 onwards), Ovid Embase (1974 onwards), Ovid PsycINFO, ProQuest PTSDpubs, Web of Science Core Collection, Cochrane Database of Systematic Reviews, NIHR Journals Library, CRD databases (archived), DoPHER, Epistemonikos, Health Evidence, 3ie International Initiative for Impact Evaluation, and PROSPERO, to identify systematic reviews of mental health interventions for involuntary migrants. We did not apply any restrictions on date, language, or publication status to the searches. We included systematic reviews or protocols for systematic reviews of interventions aimed at refugees, asylum seekers, and internally displaced persons. Interventions must have been aimed at mental health promotion (for example, classroom-based well-being interventions for children), prevention of mental health problems (for example, trauma-focussed Cognitive Behavioural Therapy to prevent post-traumatic stress disorder), or treatment of common mental disorders and symptoms (for example, narrative exposure therapy to treat symptoms of trauma). After screening abstracts and full-text manuscripts in duplicate, we extracted data on the characteristics of the reviews, the interventions examined in reviews, and the number of primary studies included in each review. Methodological quality of the included systematic reviews was assessed using AMSTAR 2.

MAIN RESULTS

The overview includes 23 systematic reviews and 15 registered systematic review protocols. Of the 23 published systematic reviews, meta-analyses were conducted in eight reviews. It was more common for the search strategy or inclusion criteria of the reviews to state that studies involving refugees were eligible for inclusion (23/23), than for asylum seekers (14/23) or IDPs (7/23) to be explicitly mentioned. In most reviews, study eligiblity was either not restricted by participant age (9/23), or restricted to adults (10/23). Reviews commonly reported on studies of diagnosis or symptoms of post-traumatic stress disorder or trauma (11/23) and were less likely to report on depression or anxiety (6/23). In 15 reviews the intervention of interest was focused on/ specific to psychological therapy. Across all 23 reviews, the interventions most commonly identified from primary studies were general Cognitive Behavioural Therapy, Narrative Exposure Therapy, and a range of different integrative and interpersonal therapies. Even though many reviews included studies of participants without a diagnosis of a mental health problem, they often assessed mental health treatments and did not usually distinguish between promotion, prevention, and treatment in the review aims. Together the 23 systematic reviews included 336 references, of which 175 were unique primary studies. Limitations to the methodological quality of reviews most commonly related to reporting of selection criteria (21/23), absence of a protocol (19/23), reporting of study design (20/23), search strategy (22/23), and funding sources of primary studies (19/23).

AUTHORS' CONCLUSIONS

Gaps exist in the evidence on mental health interventions for refugees, asylum seekers, and internally displaced persons. Most reviews do not specify that internally displaced persons are included in the selection criteria, even though they make up the majority of involuntary migrants worldwide. Reviews specific to mental health promotion and prevention of common mental disorders are missing, and there is more evidence available for adults or mixed populations than for children. The literature is focused on post-traumatic stress disorder and trauma-related symptoms, with less attention for depression and anxiety disorders. Better quality systematic reviews and better report of review design and methods would help those who may use these reviews to inform implementation of mental health interventions.

How Should Unaccompanied Minors in Immigration Detention Be Protected From Coercive Medical Practices?

Current policies and ongoing border crossings have increased the number of unaccompanied minors and the length of time they spend in detention. The US Department of Health and Human Services Office of Refugee Resettlement and its detention facilities currently determine what constitutes appropriate medical care for unaccompanied minors in immigration detention. This care might not be in a child's best interest. In contrast, juvenile detention and human subject research regulations rely on child advocates and court orders to protect children from coercion and safeguard a child's best interest. It is urgent that the medical community advocate for these same safeguards to be put in place for the unaccompanied minors in immigration detention.

[Tuberculosis among asylum seekers]

Global migration is increasing, including migration from tuberculosis (TB) high-incidence countries to TB low-incidence countries as Denmark. Asylum seekers are at increased risk of having TB, and screening for TB is potentially highly relevant in Europe. However, there is a large variation in the ways screening is carried out and in the yield of the different screening programmes. There is a need of more quality data on how effectively to target the screening among asylum seekers, considering both the TB incidence in the country of origin and the risk factors along the migration route.

[Diagnostics and initial estimation of refugee minors]

The number of underage refugees arriving in Germany has rapidly increased since 2015. Many of these children and adolescents have been and still are, exposed to a large number of stressful circumstances. The group of those helping refugee minors is heterogeneous with both volunteers and professional workers from the fields of child welfare and healthcare services. Easily applicable instruments to assess both burdens and resources are needed in order to plan appropriate interventions. This paper focuses on instruments for assessing the circumstances of refugee minors and includes pilot data of an online-based screening instrument to assess burdens and resources (providing online resource and trauma assessment for refugees, PORTA). Field application was tested by the staff of a clearing and preclearing institution with 33 cases and good practical feasibility was reported. Applying a simple to use screening instrument for refugee minors and their helpers, which is available in several languages creates the possibility of a shared definition of problems and solutions and is beneficial to helpers (e.g. volunteers, youth welfare services and medical doctors) as well as refugee minors.

Use of country of birth as an indicator of refugee background in health datasets

BACKGROUND

Routine public health databases contain a wealth of data useful for research among vulnerable or isolated groups, who may be under-represented in traditional medical research. Identifying specific vulnerable populations, such as resettled refugees, can be particularly challenging; often country of birth is the sole indicator of whether an individual has a refugee background. The objective of this article was to review strengths and weaknesses of different methodological approaches to identifying resettled refugees and comparison groups from routine health datasets and to propose the application of additional methodological rigour in future research.

DISCUSSION

Methodological approaches to selecting refugee and comparison groups from existing routine health datasets vary widely and are often explained in insufficient detail. Linked data systems or datasets from specialized refugee health services can accurately select resettled refugee and asylum seeker groups but have limited availability and can be selective. In contrast, country of birth is commonly collected in routine health datasets but a robust method for selecting humanitarian source countries based solely on this information is required. The authors recommend use of national immigration data to objectively identify countries of birth with high proportions of humanitarian entrants, matched by time period to the study dataset. When available, additional migration indicators may help to better understand migration as a health determinant. Methodologically, if multiple countries of birth are combined, the proportion of the sample represented by each country of birth should be included, with sub-analysis of individual countries of birth potentially providing further insights, if population size allows. United Nations-defined world regions provide an objective framework for combining countries of birth when necessary. A comparison group of economic migrants from the same world region may be appropriate if the resettlement country is particularly diverse ethnically or the refugee group differs in many ways to those born in the resettlement country.

SUMMARY

Routine health datasets are valuable resources for public health research; however rigorous methods for using country of birth to identify resettled refugees would optimize usefulness of these resources.

Using the International Classification of Functioning, Disability and Health (ICF) to describe the functioning of traumatised refugees

The aim of this project was to use the International Classification of Functioning, Disability and Health (ICF) to develop an interdisciplinary instrument consisting of a Core Set, a number of codes selected from ICF, to describe the overall health condition of traumatised refugees. We intended to test 1) whether this tool could prove suitable for an overall description of the functional abilities of traumatised refugees before, during and after the intervention, and 2) whether the Core Set could be used to trace a significant change in the functional abilities of the traumatised refugees by comparing measurements before and after the intervention. In 2007, eight rehabilitation centres for traumatised refugees in Denmark agreed on a joint project to develop a tool for interdisciplinary documentation and monitoring, including physical, mental and social aspects of the person's health condition. ICF, developed and approved by WHO in 2001, was found suitable because it offers a common and standardised language and a corresponding frame of reference to describe health and associated conditions in terms of functioning rather than symptoms and diagnosis. Traumatised refugees are in most cases severely affected mentally by the traumas they have been subjected to, physically by injuries suffered during torture and war, psycho-somatically with pain, and socially by cultural uprooting, as well as by social difficulties in the exile community. The rehabilitation perspective thus seems to be more meaningful than the traditional treatment perspective because it takes into account the very complex situation of this group. The aim of the project was to find out whether any functional changes could be monitored using the instrument. The aim was neither to study nor to describe the effect of rehabilitation approaches, such as conditions related to traumatised refugees' networks or environments that might affect the refugees' living conditions. It was also not the intention to discuss the cause of the potential changes of the functional abilities. The project selected a Comprehensive Core Set of 106 codes among 1,464 possible codes (1) used by an interdisciplinary group of international and national experts in rehabilitation of traumatised refugees. The Comprehensive Core Set was furthermore reduced to a Brief Core Set of 32 codes by the interdisciplinary team (key persons) at the centres included in the project. From each centre six clients were randomly selected from those who fulfilled the inclusion criteria. All were scored within a four week period after the start, before any intervention was initiated, and up to a month after the first scoring. The results from this project led us to the conclusion that it is possible to develop an instrument based on the ICF classification. The instrument is useful for a general description of the total health condition (physical and mental functional ability as well as the environmental impact) of traumatized refugees. The tool helps describe changes in the functional abilities used in connection with the preparation of the plan of action. It can also be used to describe the refugees included in the study and their general condition. The ICF Core Set for traumatised refugees has not yet been validated, but the results of the project provide a basis for further development.

Language proficiency, gender and self-reported health: an analysis of the first two waves of the longitudinal survey of immigrants to Canada

BACKGROUND

Most immigrants to Canada now come from Asia, the Middle East, the Caribbean and Africa, where cultures and languages often differ significantly from the Canadian context. Subgroups of immigrants experience disparities in health. Inability to communicate in an official language in Canada may be a marker of risk for poor health due to both pre- and post-migration factors. We aimed to study the relationship between language proficiency and self-reported health.

METHODS

We conducted a cross-sectional analysis of the first two surveys of the Longitudinal Survey of Immigrants to Canada (2001, 2003), a population-based cohort study of new immigrants to Canada. Specifically, we used logistic regression analyses to examine the relationship between self-reported health and language proficiency by sex, controlling for a range of health determinants at 6 months (wave 1) and 2 years (wave 2) after arrival.

RESULTS

After controlling for covariates (age, sex, education, region of birth, immigrant class, job satisfaction, access to health care), analysis of the wave 1 survey showed that poor proficiency in English or French is significantly related to the self-reported poor health (OR=2.0, p<0.01). And this relationship was consistent in the wave 2 survey (OR=1.9, p<0.01). We also found that this statistically significant association between poor language proficiency and self-reported health holds only for women (wave 1 survey OR=2.6, p <0.01, wave 2 survey OR=2.2, p<0.01), not for men.

CONCLUSION

The association between poor language proficiency and poor self-reported health, and particularly its significantly greater impact on women, has implications for language training, health care and social services, and health information.

Operation Child-ID: reunifying children with their legal guardians after Hurricane Katrina

Children constitute a vulnerable population and special considerations are necessary in order to provide proper care for them during disasters. After disasters such as Hurricane Katrina, the rapid identification and protection of separated children and their reunification with legal guardians is necessary in order to minimise secondary injuries (i.e. physical and sexual abuse, neglect and abduction). At Camp Gruber, an Oklahoma shelter for Louisianans displaced by Hurricane Katrina, a survey tool was used to identify children separated from their guardians. Of the 254 children at the camp, 36 (14.2 per cent) were separated from their legal guardians. Answering 'no' to the question of whether the accompanying adult was the guardian of the child prior to Hurricane Katrina was a strong predictor (27.8 per cent versus 3.2 per cent) of being listed as 'missing' by the National Center for Missing and Exploited Children (NCMEC). All the children at Camp Gruber who were listed as 'missing' by the NCMEC were subsequently reunited with their guardians.

"They think we're OK and we know we're not". A qualitative study of asylum seekers' access, knowledge and views to health care in the UK

Background

The provision of healthcare for asylum seekers is a global issue. Providing appropriate and culturally sensitive services requires us to understand the barriers facing asylum seekers and the facilitators that help them access health care. Here, we report on two linked studies exploring these issues, along with the health care needs and beliefs of asylum seekers living in the UK.

Methods

Two qualitative methods were employed: focus groups facilitated by members of the asylum seeking community and interviews, either one-to-one or in a group, conducted through an interpreter. Analysis was facilitated using the Framework method.

Results

Most asylum seekers were registered with a GP, facilitated for some by an Asylum Support nurse. Many experienced difficulty getting timely appointments with their doctor, especially for self-limiting symptoms that they felt could become more serious, especially in children. Most were positive about the health care they received, although some commented on the lack of continuity. However, there was surprise and disappointment at the length of waiting times both for hospital appointments and when attending accident and emergency departments. Most had attended a dentist, but usually only when there was a clinical need. The provision of interpreters in primary care was generally good, although there was a tension between interpreters translating verbatim and acting as patient advocates. Access to interpreters in other settings, e.g. in-patient hospital stays, was problematic. Barriers included the cost of over-the-counter medication, e.g. children's paracetamol; knowledge of out-of-hours medical care; and access to specialists in secondary care. Most respondents came from countries with no system of primary medical care, which impacted on their expectations of the UK system.

Conclusion

Most asylum seekers were positive about their experiences of health care. However, we have identified issues regarding their understanding of how the UK system works, in particular the role of general practitioners and referral to hospital specialists. The provision of an Asylum Support nurse was clearly a facilitator to accessing primary medical care. Initiatives to increase their awareness and understanding of the UK system would be beneficial. Interpreting services also need to be developed, in particular their role in secondary care and the development of the role of interpreter as patient advocate.

Experiences of hurricane Katrina evacuees in Houston shelters: implications for future planning

OBJECTIVES

To shed light on how the public health community can promote the recovery of Hurricane Katrina victims and protect people in future disasters, we examined the experiences of evacuees housed in Houston area shelters 2 weeks after the hurricane.

METHODS

A survey was conducted September 10 through 12, 2005, with 680 randomly selected respondents who were evacuated to Houston from the Gulf Coast as a result of Hurricane Katrina. Interviews were conducted in Red Cross shelters in the greater Houston area.

RESULTS

Many evacuees suffered physical and emotional stress during the storm and its aftermath, including going without adequate food and water. In comparison with New Orleans and Louisiana residents overall, disproportionate numbers of this group were African American, had low incomes, and had no health insurance coverage. Many had chronic health conditions and relied heavily on the New Orleans public hospital system, which was destroyed in the storm.

CONCLUSIONS

Our results highlight the need for better plans for emergency communication and evacuation of low-income and disabled citizens in future disasters and shed light on choices facing policymakers in planning for the long-term health care needs of vulnerable populations.

Medizinische Aspekte der Objektivierung von Folterfolgen

Migration, civil wars and other conflicts in various regions of the world have led to a drastic increase in the number of displaced persons and refugees. Associated with this development is an increase in the number of torture victims seeking asylum. This means that the medical personnel is increasingly confronted with the evaluation and therapy of torture victims. The methods of verification of sequels of torture are of utmost importance in the work-up of treatment centres for survivors of torture. Since each organ can be affected by torture, a multidisciplinary cooperation is mandatory for the examination of torture victims. In this paper we shall discuss some aspects concerning the diagnosis of injuries caused by torture which are essential for interviewing and examining torture victims in order to objectify sequels of torture.

Bosnian and Soviet refugees' experiences with health care

Studies of refugees in the United States rarely address health the first few years following resettlement in part because the refugees become subsumed under the foreign-born or immigrant category. A national study reaffirmed the so-called healthy immigrant effect, but fewer sick days and less physician use may actually reflect access problems, economic concerns, and health beliefs or practices that clash with American health care. Because statistics may mask differences in health and why people seek professional care, it is important to combine qualitative and quantitative approaches. This study examined health, illness, and health care use patterns of refugees in Northern California using a database analysis, a medical record review, and an ethnographic study of the Bosnian and former Soviet Union refugee communities. This article describes some ethnographic findings from participant observation, semistructured interviews, and focus groups, with an emphasis on people's experiences with health care, health risk behaviors, and self-care.

Health of displaced Albanian Kosovars in the former Yugoslav Republic of Macedonia: fitness to travel and health outcomes assessment

INTRODUCTION

During the 1999 conflict in Kosovo, an estimated 850,000 people were displaced from Kosovo. Many thousands of these people arrived in the Former Yugoslav Republic of Macedonia (FYROM), for whom a humanitarian evacuation programme (HEP) was conducted by the United Nations High Commissioner for Refugees (UNHCR) and the International Organization for Migration (IOM). More than 91,000 people were moved to third countries under this programme.

METHODS

A health assessment tool was designed, validated, and implemented to document the health status of the refugees prior to departure. The IOM evaluated 41,652 pre-travel "fitness to travel" medical assessments for refugees transported by the Organization. A colour coding system for fitness-to-travel was used to clearly identify refugees to the receiving health authorities according to their health condition at the time of departure.

RESULTS

A total of 41,652 fitness-to-travel assessments were performed between 05 April and 25 June 1999, and were entered into a database. There were 21,923 females and 19,566 males. The average age was 25.3 years (women, 26 years; men, 24.3 years). Of these assessments, 4,647 (11.2%) individuals who were deemed fit-to-travel required medical assessment at the host destination, and of those 1,204 required urgent care. The majority of health complaints were acute respiratory tract infections and hypertension.

CONCLUSIONS

A rapid and efficient system for fitness-to-travel was created to assist in the management of health issues related to the urgent and mass movement of refugees. The collected health information was of use to health-care planners during the crisis and for those responsible for the health-care of newly arrived refugees. The lessons learned have implications for future similar operations and for the development of research and education programs for both the refugees and the host recipient nations.

A social and demographic study of Tibetan refugees in India

The social and demographic characteristics of approximately 65,000 Tibetan refugees in India were determined from data collected 1994-1996. Approximately 55,000 refugees were living in 37 settlements widely distributed around India. The remaining 10,000 refugees were monks living in monasteries associated with some of the settlements, mostly in the south of India. In the settlements, a community-based surveillance system was established and data were collected by trained community health workers in house to house visits. In the monasteries, data were collected by the community health workers in monthly interviews with a designated liaison monk at each monastery. These data indicated little immigration of new civilian refugees in the past 10 years into the settlements but a steady influx of new monks into the monasteries. The age distribution in the settlements showed a prominent mode in the 15-25 year age range, a declining birth rate, and an increasing proportion of elderly. In general, refugees born in India were educated through secondary school, while refugees born in Tibet were often illiterate. The principle occupations were education involving 27% (including students), farming, 16%. and sweater selling, 6.5%; another 6.5% were too young or too old for employment, and only 2.4% were unemployed. The overall crude birth rate was determined to be relatively low at 16.8/1000. although this may underestimate the true figure. Infant mortality varied from 20 to 35/1000 live births in the different regions. Child vaccination programs cover less than 50% of the population. The burden of illness in this society was mainly characterized by diarrhoea. skin infections, respiratory infections, fevers, and, among the elderly. joint pains and cardiovascular problems. Although calculated death rates were unrealistically low, due to under-reporting, causes of death, derived from "verbal autopsies", were mainly cancer, tuberculosis, accidents, cirrhosis and heart disease in order of decreasing frequency. Overall, the sociodemographic and health characteristics of this population appear to be in transition from those typical of the least developed countries to those typical of middle income and more affluent societies.